Halaba Kulito General Hospital Chart Round Checklist

Patient Name: _______________________ Age: _____ Sex: ____ MRN: ____________ Date: ___________

Contents/Parameters Comment from team (if any)

1. Appropriate Clinical evaluation: Yes  No 

2. Correct Decision process: Yes  No 
3. Appropriate and justified work up: Yes  No 
4. Rational use of drugs: Yes  No 

1. Nursing care Plan filled & complete: Yes  No  New 

2. Clinical pharmacy medication care plan: Yes  No  New 
3. Progress note written & decision made: Yes  No  New 
4. Admission evaluation note: Yes  No  New 
5. WHO SSI Tracking Chart: Yes  No  NA 
6. Discharge Planning chart: Present  Absent  Complete 
7. Patient monitoring:
 VS taken according to VS Protocol/Pt condition: Yes  No 
 Fluid intake, output & balance: Yes  No  NA 
 SPO2 monitoring & correct action: Yes  No  NA 
 Daily Wt (AGN, HF, CLD, Neonate, SC): Yes  No  NA 
 Pain scored & Managed accordingly: Yes  No 

8. Labor & Delivery and Post-Partum Care:

 Parthograph use: Complete  Incomplete  NA 
 PP VS: Q30’ for 1st 2Hrs: Yes  No  NA 
 PP VS: Q2Hrs from 2hrs of PP to Discharge: Yes  No  NA 
 Documented VS for Neonate: Yes  No  NA 
 BF initiated and attachment demonstrated: Yes  No  NA 

Chart Round Team:

Name: Sign: